Reducing the risk of recurrence with medicine

Michele Almeida and Jennifer Clark are friends and breast cancer survivors who made different decisions about whether to take medication designed to prevent recurrence of cancer.
(Photo:
ALLISON HURLEY/FOR THE FREE PRESS
)

Both women were in their 30s, married with children, when in 2007 each discovered a breast lump while taking a shower. In a matter of days, each woman had gone to the doctor and been sent for further evaluation: imaging tests and biopsies.

Their medical paths would, in a matter of months, take different paths in the treatment of the breast cancer each was diagnosed with. One woman chose to take medicine to reduce her risk of breast cancer recurrence. The other woman tried several medicines, and elected not to take any due to the side effects. The story about how they made their decisions is relevant to many women with breast cancer.

Unexpected discovery

Michele Almeida, who lives in Orwell, was 32 the day she felt a hard lump in her breast.

Almeida, who is now 39, had recently stopped breast-feeding her son, then 9 months old. She wondered if perhaps the lump was a blocked milk duct.

Her primary care physician, speculating it was probably a harmless cyst, nonetheless sent Almeida for a mammogram. After further imaging tests, Almeida was asked to stay for a fine-needle biopsy.

"I wanted to hightail it out of there," she said. Her breast cancer diagnosis left her in shock, she said.

That same summer, Jennifer Clark of Sheldon, then 37, detected a lump in her breast that was painful to the touch.

"Cancer doesn't hurt," Clark's doctor assured her. Still, she asked her to come in for an appointment.

"I probably wouldn't be here if I hadn't found it," Clark said.

Clark was sent for a mammogram and subsequent ultrasound at Fletcher Allen Health Care.

"I will never forget looking at the screen and seeing this black star-like thing," she said. "Almost like a starfish."

When doctors asked Clark if she was alone at the appointment she replied yes.

"Do I need to be freaking out yet?" she asked.

Before leaving the hospital, Clark underwent two biopsies. A few days later, at work, Clark received a phone call with a breast cancer diagnosis. At the time, her children were ages 11, 9 and 5.

"I remember walking into my boss's office saying, 'I have cancer, I have to leave,' " Clark said. "I was just crying."

Almeida and Clark underwent similar stages of treatment: surgery, chemotherapy and radiation. The next phase of their medical treatment, however, would involve different modalities.

Almeida takes an anti-estrogen medication, tamoxifen, to reduce her chance of recurrence. Clark does not.

Weighing the positives and negatives

About 80 percent of breast cancers are estrogen-receptor positive, according to Dr. Kim Dittus, an oncologist at Fletcher Allen Health Care. (Dittus is not the oncologist who worked with either Almeida or Clark.)

This means the cancer cells have estrogen receptors on their surface, and the body's estrogen can stimulate the growth of cancer cells in breast tissue. Certain medications—by various mechanisms —interfere with how estrogen stimulates growth of cancer cells.

Taking such medication is a standard part of breast cancer treatment because the anti-estrogen drugs reduce the risk of recurrence. Anti-estrogen therapy is standard treatment for breast cancer patients of all disease stages, Dittus said. The length of treatment is evolving from five to 10 years, with recent studies showing that longer therapy is better in terms of overall survival, she said.

The rate of recurrence reduction depends on the stage of cancer, Dittus said.

"Interfering with estrogen receptors was one of the first targeted therapies for cancer," Dittus said.

The treatment is offered to all patients, unless there is some sort of unusual contra-indication to the medicines, she said. It is the standard of care for breast cancers that are estrogen-receptor positive.

"I would say the majority do take it for various lengths of time," Dittus said. "It's not that common that someone tries it and says I'm not going to do this."

It was offered to both Almeida and Clark.

Almeida is the community events specialist for the American Cancer Society. At the time of her diagnosis, she worked in the development office at Middlebury College.

In the spring of 2008, after her active treatment was complete, Almeida's doctor met with her oncologist.

Because her cancer was estrogen-receptor positive and progesterone positive, Almeida's doctor prescribed tamoxifen.

The first year she took the medicine, Almeida experienced routine hot flashes she described as "bad."

"I think your body is still adjusting," Almeida said. The hot flashes often woke her up at night.

She was reminded of times in the past driving with her mother, who was experiencing menopausal hot flashes.

"Open the car window," her mother would say.

Almeida thought her mother was being dramatic. "I should've been more sympathetic," she says now.

She put her own hot flashes into perspective:

"I just thought it didn't matter," Almeida said. "I'd already been through so much. It was minor in comparison to surgery and having toxic chemicals go through your body and being radiated. Come on: a minute hot flash goes through your body. I'm not going to complain about it. And I was feeling thankful that I did have a drug that I could take that was going to help me live longer."

Michele Almeida and Jennifer Clark talk about how they came to decide whether or not they should take medications designed to prevent a recurrence of breast cancer. Side effects can be significant for some women, but most opt to take the medication.
(Photo:
ALLISON HURLEY/FOR THE FREE PRESS
)

"My body just hurt"

Clark on Monday will start a new job at the American Cancer Society, where she has been a volunteer for about five years. Today is her last day working in accounts payable at Dynapower in South Burlington.

"I'm so totally psyched," she said of her new job.

Clark does not take any anti-estrogen drugs, having tried three medications over the course of about six months. She stopped due to debilitating side effects, Clark said.

"My body just hurt," Clark said. "I just hurt all over. You couldn't even touch me."

She tried a different drug and experienced a similar phenomenon: pervasive body ache worse than the flu. Clark began taking the painkiller OxyContin on a daily basis to combat the pain.

After several months, Clark decided she would no longer take the drugs.

"I said I'm done. I can't do this anymore," she recalled. "I feel like crap. I'm so drugged up. My whole body ached."

She asked her doctor if he could guarantee she would not have a recurrence of cancer if she remained on the tamoxifen. He could not, Clark said.

She told him she felt quality of life was of paramount importance.

"I'm missing out on my kids' lives and there's no guarantees," she said. "By then I made up my mind. I said if I get it again, I'll fight it again."

This kind of pain is fairly common with aromatase inhibitors, a class of anti-estrogen drugs, said Dittus, who is not Clark's doctor. It is usually joint pain but could be felt all over, she said.

"I'm in a circle of a lot of breast cancer friends," Clark said. "I had two friends who stopped taking it as well for the same reason."

Clark had a long conversation with her oncologist about her decision, and related that he was "very concerned" about her chance of recurrence.

"By not taking the tamoxifen, I think I was a 20 to 30 percent chance of getting it again," Clark said. "But I thought, I'm 70 to 80 percent of not getting it."

On the advice of her doctor, Clark had a hysterectomy.

Recently, Clark had her seven-year mammogram. The images showed no sign of cancer, she said.

Finding the right medicine

Tamoxifen is typically prescribed for women who are pre-menopausal, while aromatase inhibitors are more likely to be prescribed for patients who are post-menopausal.

The most typical side effects of tamoxifen are hot flashes, Dittus said. There is also a small risk of endometrial cancer and a small risk — less than 1 percent — of blood clots, she said.

The most medically concerning side effect of aromatase inhibitors is loss of bone density, according to Dittus. Other side effects include bone/joint aches as well as hot flashes.

"If someone lost a lot of bone density while taking an aromatase inhibitor and we thought their risk of having a fracture was high, we may add another medicine to strengthen their bones," Dittus said. "Or we may stop the inhibitor depending on the length of time they are on it."

In general, oncologists are able to find a workable drug for patients who experience side effects.